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In light of this consistent observational evidence, exposure to antibiotics other than those intended to treat CDI should be avoided unless absolutely indicated. The two first-line antibiotics used most often to treat CDI in North America are metronidazole and vancomycin; a third, fidaxomicin, was approved for treatment of CDI in 2011.
Treatment for CDI can be initiated before laboratory confirmation for patients with a high pre-test suspicion of disease. Two older RCTs that compared vancomycin and metronidazole for treatment of CDI did not demonstrate superiority of metronidazole compared with vancomycin (33,49). However, two more recent RCTs concluded vancomycin is superior to metronidazole for patient with severe CDI (50,51).